TECHNOLOGIES FOR UNDERSTANDING AND PREVENTING SUBSTANCE ABUSE AND ADDICTION

US Government Office of Technology Assessment

APPENDIX A: DRUG CONTROL POLICY IN THE UNITED STATES: HISTORICAL PERSPECTIVES

The United States has always been a drug-using country. In colonial days, people drank
more alcohol than they do today, with estimates ranging from three to as many as seven
times more alcohol per year (13) While public drunkenness was a criminal offense, it was
generally considered a personal indiscretion. (1). The temperance movement began in
earnest after the Revolution, when heavy drinking was revealed to be a problem, and
religious figures became committed to temperance. (1). Since then, the American experience
with both licit and illicit drugs can be viewed as a series of reactions to the public's
shifting tolerance toward their use (9).

THE EARLY 1900s: NARCOTICS AND COCAINE

In the late 19th century it was possible to buy, in a store or through mail order, many
pseudomedical preparations, containing morphine, cocaine, and even heroin (9). The
ubiquitous soft drink Coca-Cola used to contain cocaine until 1903, when it was replaced
with caffeine (9). Pharmacies sold cocaine in pure form, as well as a number of
opium-derived drugs, such as morphine and heroin, the latter of which became well-known
when it was marketed by the Bayer Co. beginning in 1898 (10). Physician prescriptions of
these drugs increased from 1 percent of all prescriptions in 1874 to between 20 to 25
percent in 1902; they were not only available but they were widely used, without major
concerns about negative health consequences (14).

Cocaine and narcotic preparations were taken off the market for various reasons.
Increasing awareness of the hazards of drug use and adulterated food led to such
regulations as the Pure Food and Drug Act of 1906 that required that fraudulent claims be
removed from patent medicines, as well as disclosure of habit-forming substances. The
passage of several antinarcotic and pharmaceutical labeling laws was spurred on by these
health concerns, a growing temperance movement, the development of safe pain relievers
(such as aspirin), a broader range of medical treatments, and the growing immigrant
population thought to be associated with specific drug-using practices. However, these
laws did not make patent remedies, cocaine, and opium illegal. Some individual states
imposed tighter restrictions on their availability, but there was no uniformity among
state laws. It was United States involvement with international narcotics concern that led
there (9,10,14).

In 1909, the International Opium Commission called by the United States, met in
Shanghai, to begin an international discussion concerning the problems of narcotics and
the narcotics trade. Twelve nations, in addition to the United States, were present to
discuss problems relating to opium. At that time the perception in the United States was
that Chinese immigrants were to blame for the opium smoking problems. This angered the
Chinese, who had instituted strict campaigns against the sale and use of opium within
their own country. The Chinese were seeking U.S. assurances for help in ending Western
opium trafficking into China. The State Department not only wanted to support China's drug
control efforts, but thought that international drug control measures would help stanch
the flow of drugs into the United States, and thus the nonmedical consumption of these
drugs. It would not be until two years later, in the Hague, that a treaty would be signed
stating that all the signatories would enact domestic legislation controlling narcotics
trade, specifically limiting the use of narcotics for medicinal purposes (9,10).

Hamilton Wright, the State Department's opium commissioner, attempted to draft
legislation but met opposition from the States, the medical profession, pharmacists and
pharmaceutical companies. After nearly three years of debate, Congress passed the Harrison
Act in December 1914 (named for Representative Francis Burton Harrison, who introduced the
initial form of the bill for the Administration). The bill provided for strict control of
opium and coca and their derivatives: both their entry into the country and their
dispersion to patients. Maintenance of addicts by physicians was allowed until 1919.
Opposition to the Harrison Act came mainly from pharmaceutical companies and pharmacists,
who objected to what they called the Act's confusing and complex record keeping
requirements (9).

Passage of the Harrison Act reflected, in part, growing public sentiment that opium and
cocaine were medicines to be taken only in times of illness (and then only when prescribed
by a physician) and that these substances could cause insanity and crime, particularly in
foreigners and minorities. Smoking opium was associated with Chinese immigrants; popular
belief also held that cocaine would affect blacks more forcefully than whites and incite
them to violence. Marijuana was believed to have been brought into the country and
promoted by Mexican immigrants and then picked up by black jazz musicians. These beliefs
played a part in the 1937 Marijuana Tax Act, which attempted to control the drug's use
(9). As early as 1910, many people argued against any nonmedical use of narcotics.

PROHIBITION AND BEYOND

Focus on Alcohol

Ratification in 1919 of the 18th amendment prohibited the manufacture, sale,
transportation, importation, and exportation of alcohol and shifted the Nation's focus for
more than a decade from the dangers of narcotics to the Nation's alcohol problems.
Prohibition had its roots in the Temperance Movement, which began shortly after the
Revolution. In 1784, Benjamin Rush, a physician and signer of the Declaration of
Independence, published a pamphlet entitled, "An Inquiry Into the Effects of Ardent
Spirits on the Mind and Body," which was widely disseminated among Temperance
leaders. In it he described a "disease model" of excessive drinking, which
characterized drunkenness and alcohol addiction as a "disease of the will," in
addition to causing many physical diseases. By the mid-19th century, the American middle
class had become more aware of the dangers of alcohol to the family, the nation, and the
factory (1). By the late 19th century and early 20th century, the Temperance Movement came
to be associated almost exclusively with American Protestantism as a political mechanism
to control the growing numbers of non-Protestant immigrants. This political and social
strength helped, in 1919, to ratify the 18th amendment which forbade the sale of alcoholic
beverages, and to implement it by means of the Volstead Act in 1920 (1).

The shifting tolerance of Americans toward substance use is evidenced by the successes
and failures of the Prohibition era. In 1919, many were optimistic that the prohibition of
alcohol would solve many of the country's social problems. If alcohol contributed to the
crime and unemployment associated with the cities, then removing it from the market might
help solve those problems. However, despite evidence that consumption declined (based on
declining rates of death due to cirrhosis and of alcoholic psychosis in State mental
hospitals), there is also evidence that widespread dishonesty existed in the enforcement
of dry laws. Jobs to enforce Prohibition were doled out as political favors, which may
have contributed to graft, corruption, and the surge in underworld crime (9,17). In
addition to the perceived rise in corruption, the passage of progressively stricter laws
regarding violations of the Volstead Act also contributed to waning public support of
prohibition (17). The 1933 repeal of Prohibition signaled that public sentiment had once
again become favorable toward alcohol, and alcohol and its related problems returned to
private, rather than public, arenas.

The scientific literature of the 1930s and early 1940s concentrated mainly on captive
alcoholic populations in jails, mental hospitals, and skid row, allowing many Americans to
distance themselves from alcoholism (1). During this same period, Alcoholics Anonymous
(AA) was founded, but lacked mainstream recognition until the 1950s and 1960s when the
scientists lent support to the disease model of alcoholism, which has always been the
central tenet of AA (1,11).

Focus on Narcotics

While alcohol experienced a transition period in respect to public tolerance, negative
attitudes toward narcotics and other drugs remained constant, or became even more severe.
During the 1920s, the Federal government expanded its antidrug efforts through new
Treasury Department regulations (8). In 1930, President Hoover created the Federal Bureau
of Narcotics and appointed Harry Anslinger as the Commissioner of Narcotics, a position
Anslinger held from 1930 to 1962, a precursor, perhaps, to the modern day drug czar. For
more than three decades, Anslinger oversaw all aspects of drug control, from interdiction
to domestic supply, to public relations. He effectively used religious and other antidrug
groups to maintain a high antidrug sentiment in the country. He also controlled the flow
of legal drug supplies, by keeping watch over doctors who might prescribe unusually large
amounts of narcotics. Anslinger was opposed to the medical treatment of addiction, and
addicts, like alcoholics, were seen as deviants (9,15).

Prior to the mid-1960s, marijuana use in the United States was mostly confined to
various subgroups such as Mexican laborers, jazz musicians, and beatniks. Although
portrayed as a killer weed and a menace by antimarijuana reformers, there is little
evidence that it was either at this time. In 1937, the Marihuana Tax Act (the Federal
government then spelled marijuana with an "h"), became law, making the use and
sale of marijuana without a tax stamp Federal offenses. Some companies were permitted to
apply for a license to use cannabis products (e.g., for birdseed, paint and rope), and
doctors could still prescribe marijuana in limited circumstances. However, starting in
1937, recreational use was punished with greater severity (15). Some speculated that the
passage of the Marihuana Tax Act resulted from strong anti-Mexican sentiment in the
Southwest and the political power of Anslinger (5).

Intolerance toward drug use was very strong in the 1930s and 40s. Federal laws
concerning the sale and use of drugs got progressively stricter, culminating in the
introduction of the death penalty for the sale of heroin to anyone under 18 years old by
anyone older than 18 (10). Illicit drug use during these decades was low in the mainstream
population. This marginalization of narcotics (or at least, of the people who used them)
may have played a part in the resurfacing of these drugs after the 1930s. There was a
concern during World War II that American soldiers in Asia would succumb to drug supplies
available in those countries and return home with drug habits. The Bureau of Narcotics
received no budget increases, since Congress apparently believed it was well equipped to
deal with the current drug levels (9).

In the 1950s, however, heroin was brought into the country in larger quantities than at
any time since it was outlawed. Dealers learned that poor quality heroin could be sold at
inflated prices, and this higher cost pushed users into criminal lifestyles heretofore not
seen on such a wide scale (12). A nationwide scare that drug use would spread from the
urban poor (mostly minorities) to the rest of the country erupted. The fact that young
people appeared to be the biggest users of heroin was particularly alarming. This fear was
reflected in the passage of the Narcotic Control Act of 1956, which increased penalties
for the sale and possession of marijuana and heroin (15).

The reaction to this rise in drug use was not entirely fearful, however. Scientific and
technological advances offered alternative answers to coping with the drug problem a
switch from the past tactics of law enforcement. Even though the stereotypical heroin user
was still a poor minority, new ideas for treating and helping these people emerged as part
of increasing acceptance of the medical model of addiction. In the 1960s, methadone
maintenance pilot programs were launched. By using the long-acting opioid methadone for
treatment of addiction to the short- acting opiate heroin, these programs offer a way for
heroin addicts to control their addiction (6).

1960s-PRESENT

In the 1960s, white middle-class youths, who were more visible than their minority
counterparts, began experimenting with drugs, including marijuana and heroin, causing wide
public concern and demand for more treatment approaches and additional law enforcement
(17). Some of this new interest in drug use may be attributed to the intolerance toward it
in the preceding decades. Marijuana had never been widely used, and after the 1930s its
use was not a widespread concern. It was rediscovered by young people in the 1960s, who
had grown up with parents who used alcohol. Some of the drug consumption may also be
linked to an increase in consumption generally during the late 1960s and early 1970s, the
Vietnam War protest movement, and the rapid changes in American society that occurred in
those years (9,10,17).

Despite the image of the sixties as a time of widespread experimentation, the increase
of drug use activated many who had been quiet on the issue. Marijuana, the drug of choice
among many young people, was seen by some researchers as the gateway to more dangerous
drug use. Richard Nixon was elected President in 1968 on a law and order platform, and it
is said that no other President has campaigned as hard against drug abuse (9). As during
World War II, concern rose that soldiers serving in Southeast Asia would develop drug
habits while there. In this case, the fears were well- founded, as many servicemen did
avail themselves of cheap supplies of heroin and marijuana. However, even among those who
became addicted, many stopped their drug use upon returning to the United States. During
the 1960s, the old linkages between corruption, Asians, and opium surfaced once again in
public opinion, leading to more stringent measures to stop the flow of drugs into the
United States from both Asia and Latin America (8).

Public support of law enforcement against drugs was high during the late 1960s and
early 1970s, and President Nixon spoke of mounting "a frontal assault on our number
one public enemy [drugs]," but long mandatory minimum sentences for possession of
small amounts of marijuana disturbed many Americans, even those who did not approve of
marijuana use. The Comprehensive Drug Abuse Prevention and Control Act of 1970 lessened
penalties for possession of marijuana. It also established a system for classifying drugs
into five schedules, which is still used today. Drugs are placed in each schedule based on
their potential for abuse, their known harmfulness, and medical value. Marijuana and
heroin are listed in schedule 1--drugs with high potential for addiction and no recognized
medical value. There have been, however, limited experimental programs approved by the DEA
and FDA for the use of marijuana in treatment of nausea due to chemotherapy and of ocular
pressure due to glaucoma. Cocaine is listed in schedule 2--drugs with potential for
addiction for acceptable for some medical applications. Subsequent to the establishment of
this system, drug policies and laws for individual drugs have been based on the drug's
schedule (3,16).

In 1972, the President's National Commission on Marijuana and Drug Abuse recommended
that the laws against the use of marijuana be relaxed, since the enforcement of these laws
was becoming too burdensome to police in some areas, and was considered intrusive on
individual privacy in others. The drug was increasingly thought to be innocuous in its
effects, both by scientists and others (4). Several States passed decriminalization laws,
which allowed possession or use of small amounts of marijuana and imposed fines instead of
prison sentences for transgressions of minor possession laws (10). The Commission remained
strict on cocaine, which was also seeing a surge in use, but few experts thought it was
physically addictive or should be classified in the same category as other narcotics.

Despite President Nixon's emphasis on "law and order" responses to drug use,
his drug budget favored prevention, education, and treatment. The National Institute on
Drug Abuse (NIDA) was created as the lead agency for demand reduction, directing Federal
prevention and treatment services and research. The Drug Enforcement Administration was
created as the lead agency for supply reduction, and single state agencies were created to
guide Federal funds into state and local antidrug programs (3).

From the mid-sixties to the late seventies, the composition of drug users changed
substantially. While drug use was still associated primarily with minorities and the lower
classes, drug use by middle-class whites became a widespread and more accepted phenomenon.
As in the late nineteenth and early twentieth centuries, when middle class whites
haphazardly used narcotic preparations, this new group of drug users down-played or
ignored the dangerous effects of drugs, and extolled their virtues as agents of
nonconformity and mind-expansion. Cocaine was an expensive and high-status drug, used
mainly for recreation by upper- and middle-class whites.

From the drug experiences of this cohort, which were by no means entirely positive, the
public of the late seventies was better educated about the effects of drugs, and public
disapproval of drug use began once again to increase. Drug use, however, particularly of
cocaine and marijuana remained high. The Ford Administration (1974-1977) focused on the
drugs it thought posed the greatest danger--heroin, amphetamines, and barbiturates. Some
even thought that drugs such as cocaine and marijuana should be legalized, "so as to
end the enormous government expenditures of money and time on a problem that only seemed
to bring profits to drug dealers and elicit contempt for the law from an ever-growing body
of drug users" (9).

During the Carter Administration (1977- 1981), Peter Bourne, a special assistant for
health issues, argued for Federal decriminalization of possession of small amounts of
marijuana, while focusing interdiction efforts on heroin. But Bourne resigned over a
scandal involving criticisms over his prescribing practices. His resignation forced
President Carter to take a harder position on drugs, and Federal decriminalization never
occurred. There were still States in which marijuana was decriminalized, but these
decreased in numbers through 1990, when the last State--Alaska--to have decriminalization
repealed those laws.

The departure of Bourne coincided with the emergence of several parents' groups
concerned about drug use by their preteen children. One group in particular, in Atlanta,
Georgia, became enraged when they found that in addition to drug use at parties, their
children were able to buy drug paraphernalia and prodrug literature in local stores. The
group formed the Parent Resources Institute on Drug Education, National Families in
Action, and the National Federation of Parents. These groups were instrumental in prodding
NIDA to publicize more widely the dangers of marijuana and other drugs once thought of as
harmless.

The Administration of Ronald Reagan (1981-1989) favored a strict approach to drug use
and increased law enforcement. First Lady Nancy Reagan actively campaigned against drug
use, urging school children to "Just Say No." At the same time, funding for
research and treatment decreased, while the availability of cocaine, heroin, and marijuana
remained the same (9). The budget for antidrug related activities rose from $1.5 billion
in 1981 (split nearly equally between supply reduction (domestic law enforcement and
international/border law enforcement) and demand reduction (research, prevention and
treatment) to $4.2 billion by the end of President Reagan's second term. Two-thirds of the
funds were now allocated for law enforcement activities, with the remaining third
allocated for demand reduction (2). In 1984, the Crime Control Act increased dramatically
Federal mandatory minimum sentencing provisions for drug- related crime, including the
manufacture, distribution, or possession of controlled substances. It also expanded the
criminal and civil asset forfeiture laws to penalize drug traffickers and increased
Federal criminal penalties for drug-related offenses (3). This trend continued through the
remainder of the Reagan administration as well as that of President Bush.

The 1980s saw significant shifts in patterns of cocaine use. The negative effects of
cocaine use, especially long-termuse, had previously been masked, but middle-class users
with drug-related problems suddenly were more common. Concurrently, cocaine smuggling
escalated, resulting in increased availability, lower prices, and higher quality.
Low-income, minority communities began experiencing major drug problems, first with
powdered cocaine, then in the mid- eighties especially with the new form of
cocaine--crack. Commonly called an epidemic, the spread of this smokable cocaine inspired
both President Reagan and antidrug groups to heightened drug intervention efforts. Crack
appeared to be highly addictive, as well as affordable, and fear of its consequences
forced many lawmakers into action. The Anti- Drug Abuse Act of 1986 authorized more funds
than ever before for the war on drugs, most of which was designated for international
interdiction activities (9), and the establishment of the Office of Substance Abuse
Prevention (OSAP). The AIDS epidemic has also affected patterns of drug use, since some
intravenous (IV) drug users may have switched to smoking crack in order to avoid exposure
to the AIDS virus. Other IV drug users, however, have continued to inject, and comprise a
large percentage of the AIDS-infected population.

While the main focus of drug control policy in the 1980s was interdiction of illicit
drugs, significant policy initiatives concerning alcohol were also implemented. For
example, the goal of the national minimum drinking age of 21 was stated in 1984 and
achieved by 1988. Warning labels were required on all retail containers of alcoholic
beverages beginning in 1989 (7).

When George Bush was elected President in 1988 the climate within the country was
highly intolerant to the use of illicit drugs. President Bush echoed President Nixon when
he declared that the drug epidemic was "public enemy number one" (16). The
Anti-Drug Abuse Act of 1988 mandated the creation of the Office of National Drug Control
Policy (ONDCP), to be headed by a director, sometimes called the drug czar, who would
coordinate U.S. drug control and abuse policy, resources, and operations (Public Law
100-690). The first director was William Bennett, former Secretary for Education under
President Reagan. He was followed by Robert Martinez, former Governor of Florida. The
director, in conjunction with the President and Cabinet Secretaries, sets Administration
policy on drug control. However, ONCDP lacks budgetary authority, and under President Bush
the director of ONDCP was not a Cabinet position. During the Bush Administration,
additional funds were authorized for the war on drugs, including increased funds for
treatment and prevention. However, most of the funds were designated for law enforcement
activities. Spending for antidrug-related activities rose from the high of $4.2 billion
under President Reagan, to a proposed $12.7 billion in the last year of President Bush's
term. Again, the monetary split was roughly two-thirds for law enforcement and
international interdiction activities and one-third for demand reduction (2).

While "The War on Drugs" has remained part of the political lexicon,
President Clinton, after taking office in 1993, cut the Office of National Drug Control
Policy from 146 positions to 25. He elevated the director of ONDCP to cabinet status, and
Lee P. Brown, former Police Commissioner of New York City was appointed to this position.
During his campaign for the presidency, Clinton advocated drug treatment on demand, and
the addition of 100,000 new police officers to the streets. _